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Procedure for Accident & Incident Investigation

Chairman (OHSC)

1.0 INTRODUCTION
Accidents happen when hazards escape detection during the planning of preventive measures, such as during hazard identification & Risk Analysis process or as a result of combinations of circumstances that were difficult to foresee. A thorough accident investigation may identify previously overlooked physical, environmental, or process hazards, unsafe work practices and also the need for new or more extensive safety training, improved work practices and the like. The primary focus of any accident investigation is determination of the underlying facts leading to the incidents and the lessons that can be learned to prevent similar occurrences in future.

The focus of the investigation should NEVER be to place blame on anyone but to explore opportunities for improvement.

2.0 PURPOSE
The purpose of this procedure is i) ii) To adopt a uniform methodology for investigating the incidents/accidents To identifying all contributing factors of the accident/incidents and hazardous situations and making the necessary recommendations to prevent the accident/incident from recurring. To identify the duties, roles and responsibilities of persons so that an effective and immediate accident/incident investigation and reporting process can be implemented.

iii)

3.0 Which incidents/accident to investigate & by whom

The following categories of accident/incidents require an immediate investigation as they may result into loss to people, equipment, material property and environment:
a. b.

Fatality An injury that results in loss of life Major Injury If the injury places human life in jeopardy; produces
unconsciousness; results in substantial loss of blood; involves the fracture of a leg, or arm but not a finger or toe; involves the amputation of a leg, arm, hand, or foot but not a finger or toe; consists of burns to a major portion of the body; or causes the loss of sight in an eye.

c.

Lost Time Accidents A work related injury that results in the injured
employee missing scheduled time from work resulting in a wage loss

d.

Property Damage - When there is significant damage to company property

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e.

Chairman (OHSC)

Occupational Illness A condition that results from exposure in a

workplace to a physical, chemical or biological agent that normal physiological mechanisms are affected and the health of the employee is impaired

f. g.

Environmental Release An accidental discharge of a physical, biological

or chemical substance into the workplace and/or community

Fire/Explosion An event where undesired combustion occurs

The level of investigation and documentation required depends upon recordability and

severity. Responsibility of investigation: 1. All major accidents/incidents shall essentially be investigated by the respective HOD
along with Incharge Safety/Investigation officer and the concerned Section Incharge.

2. All minor accidents/incidents shall be investigated by the respective Section

Incharges & other section team members.

4.0 ROLES & RESPONSIBILITIES

1. Section Incharge (Investigator) Responsibilities
i)

The Section Incharge of the area where the accident/incident happened investigates the accident / incident and completes the Investigation Report (R/2113) within 24 hours of the accident/incident. Forward the completed Accident/Incident Report Form (R/21-12 or R/21-14 as the case may be) and Investigation Report (R/21-13) to Incharge (Safety) within 48 Hours of the incident. In the case of personal injury, the Section Incharge ensures that the injured employee (s) receives immediate and appropriate attention, first aid and/or health care. The Section Incharge or Supervisor on duty shall immediately report those accidents that result in major injury to Incharge (Safety) or Main Security Gate and to his HOD by phone. In conducting the accident/incident investigation and completing the Investigation Report, the Section Incharge must ensure that the following investigation requirements have been completed:

ii)

iii)

iv)

v)

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(a)

Assessment of the Scene

a.

Inspection of the site, equipment, material that were involved in the accident /incident

b. Site must be secured especially after a major injury

c.

Use of photographs, sketches, drawings of the accident /incident scene, if required.

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Chairman (OHSC)

(b)

Interviews
a. Interview employee(s) involved b. Interview any eyewitnesses c. Interviews must be documented d. Interviews should be conducted as soon as possible e. Interviews should not be conducted in public but one-on-one in a quiet place

(c)

Identifying the contributing factors

(i) Hazardous Conditions (factors) to consider are: a. People, b. Equipment, Tools c. Material, d. Environment, e. Process f. Vehicles g. Animals (ii) Unsafe Behaviours (factors) to consider are: a. Failing to comply with rules, procedures b. Using unsafe methods/practices c. Taking shortcuts d. Horseplay e. Failing to correct the known defects f. Failing to report injuries g. Scheduling too much work h. Failing to report hazards i. Working under too much stress

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The above mentioned factors are examples only. There can be many more other factors responsible for any particular incident. The investigator should look into all the aspects before reaching a conclusion.

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Chairman (OHSC)

(d)

Analyze the root causes

Root causes may be divided into 2 categories: System Design weaknesses: Missing or inadequately designed policies, programs, plans, processes and procedures that affect conditions and practices throughout the workplace. Defects in system design represent hazardous system conditions.
(i)

(ii)

System implementation weaknesses. Failure to initiate, carry out, or accomplish safety policies, programs, plans, processes, and procedures. Defects in implementation represent ineffective system.

(d)

Writing the report

Record all findings on the standard investigation form (R/21-13) ensuring that all requirements of the written investigation procedure are completed.

(e)

Make recommendations for corrective & preventive actions

a. Responsibilities (by name & by post) must be assigned for completion of the Action Plan b. Record the Action Plan on the Investigation Report form itself or as an attachment c. Recommendations should focus on the corrective action(s) for all the contributing factors identified d. Recommendations for Corrective Actions should clearly specify

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What is to be done? How it will be done? Who will do what?

(f)

Follow up actions to ensure that recommendations are acted upon

a. Assign responsibility for the follow-up of the corrective action(s)

b. During the follow up, record the date of completion of the job and ensure if the job has been done as per the stated requirements c. Ensure the recommendations are communicated to the concerned HOD.

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Chairman (OHSC)

2. Responsibilities of Safety Cell

i)

To review all Accident/Incident Reporting Forms and Investigation Reports and follow up as appropriate/required. To ensure that recommendations are appropriate and that corrective and preventative actions have been taken. To assist or provide direction as needed for the implementation of corrective actions. To ensure reports are distributed to any areas requiring information for subsequent follow up of additional corrective action or for injury treatment etc. If an accident results in a "critical or major injury, Safety Cell will immediately notify the concerned regulatory authorities as required by the law.

ii) iii) iv)

v)

3. Employees Responsibilities
i)

Immediately reports to supervisor any work related injury/illness. This includes accidents such as cuts, puncture wounds, needle stick injuries, sprains and burns as well as those that are on a gradual onset (chronic) i.e. back pain, repetitive strain. Immediately reports to supervisor any "near miss" events and/or unsafe work situations and provide necessary details to the supervisor. Extend full Cooperation to the investigating team If an employee has to leave the workplace due to a work related injury or illness, he/she is advised to go first to the Health Centre at Binanigram during normal working hours. During odd working hours, doctor may be called to the Health Centre if the situation so demands. Alternate medical attention should be sought if the factory doctor is out of station.

ii) iii) iv)

v) vi)

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4. Workplace Health Services Responsibilities

i) ii) Administers first aid measures as necessary and determines need and arranges for treatment referrals as needed. Arranges for follow up medical assessments of ill/injured employee.